Obstetri Emergency Team

Duty Report
Tuesday, February 20th 2015
Supervisor :
dr. Riza Hendrawan Nasution, Mked(OG), Sp.OG
Resident :
1. dr. Ria Suci Nurlianti
2. dr. Vivi Yovita
3. dr. Ormias Pratama

Department of Obstetric and Gynecology

Medical Faculty of Universitas Sumatera Utara
Pringadi General Hospital
2015

Prior patient
patient
New patient
patient

1. 6

Mrs. I, 33 yo, G3P1A1

Diagnosis
: Secundigravida + Intra Uterine Pregnancy (36-38) WGA + Head Presentation + Alive
Fetus + in labor
Planning
: monitoring vital sign, uterine contraction and Fetal heart rate
Monitoring labor progress spontaneus vaginal delivery

1. Mrs. I, 33yo, G3P1A1, Bataknese, Christian, Senior high school, housewife, married
to Mr. D, 35 yo, Bataknese, Christian, Senior high school Enterpreneur. The patient
was arrived in Pringadi Hospital ER, on february 20th 2015 at 9.00 am:
CC
: Uterine contraction
H
: it was felt by the mother since 05.00 am (20/2/2015), history of bloody show (-),
history of rupture of amniotic fluid leakage (-). Micturition (+) and Defecation (+) in
normal limit
Previous illness
Previous medical history
LMP
EDD
ANC

: 25- 5 - 2014
: 2 3 - 2015
: Midwife 8x

: (-)
: (-)

History of labor
1.boy, aterm, 2800gr, SVD,
Midwife, clinic, exitus in 1 yo
2.This pregnancy

Present State
Consc
: compos mentis
Anemic
BP
: 110/70 mmHg
Icteric : (-)
HR
: 80 x/i
Cyanotic
: (-)
RR
: 20 x/i Dypsnoe
: (-)
Temp
: 36,5C
Oedema
: (-)

: (-)

General State
Head

: Conj Palpebra inferior anemic(-)/(-), sclera icteric

(-)/(-)
Neck

: in normal limit

Thorax

: Lung : Respiratory sound: Vesiculer (+)/ (+)

Additional sound: Wheezing(-)/(-), Rales (-)

Cor : S1/S2 reguler, murmur (-), gallop (-)
Extremity

: oedema (-)/(-) pretibial, KPR (+)/(+) N

Obtetrical State
Abdomen

: Symmetrically enlarged

Fundal Height : 3 fingers above Proc. Xypoideus

Tense part
Lowest part

: head

FM

: (+)

: Left

Uterine cont. : 2 x 10/10

FHR

: 144 x/I

EFW

: 2600- 2800 gr

USG TAS

USG TAS

USG TAS

Singleton, Head presentation, Alive

FM (+), FHR (+)
BPD : 9.03 cm
FL : 7.38
AC : 33.7 cm
Amniotic fluid within normal limit
Placenta corpus anterior
Conclusion
: IUP (36-38)wga + Head presentation + Alive

LABORATORY FINDINGS
Hb
Leucocyte
Hematocrit
Platelet
PT
INR
APTT

: 9,3
: 15.800
: 29,30
: 279.000
: 12
: 0,95
: 40,5

N: 12-14 gr/dL
N: 4000-11000/uL
N: 36,0-42,0/%
N:150.000-400.000/uL
C: 14,1
C :1-1,3
C : 32,7

Dx : Secundigravida _+ IUP (36-38)wga + Head Presentation + Alive + Inlabor

Therapy :
IVFD RL 20 dpm
Planning :

monitoring vital sign, uterine contraction and Fetal heart rate

Monitoring labor progress spontaneus vaginal delivery

Partograf

Spontaneous Vaginal Delivery with EV

report

Mother laid in ginecology table with i.v. line installed properly,

in an adequate contraction the head was forward and backward in
vaginal inlet. And then persist. (Media lateral episiotomi was done)
Vakum cup was installed as closed as posible to the fontanella,
vakum cup evaluation : no mother part was squeezed by vacum
Vacum pressure was increased, started from 0.2, 0.4, 0.6 kg/ cm 2,
evaluation of the birth canal squeezed
In the next adequate contraction, controlled traction was done, in
the same direction with the birth canal and then born baby head,
the cup was open and born all the body. And then born baby boy,
BW : 2800 gr, BL :47 cm, AS 8/9, anal (+).
With PTT, plasenta was born, impression complete.
Explore vaginal canal found second grade laceration and repaired.
Mother condition after vaginal delivery is stabil.

 Th/ - IVFD RL 20 bpm

Inj. Ceftriaxone 1 gr/12 hours
Metronidazol drip 500 mg/ 8 hours

Laboratory finding after SVD with EV

Hb
Leucocyte
Hematocrit
Platelet

: 9,9
: 30.600
: 31,10
: 281.000

N: 12-14 gr/dL
N: 4000-11000/uL
N: 36,0-42,0/%
N:150.000-400.000/uL

THANK YOU